1. Manages the Risk Management program and is responsible for investigating and reporting all accidents/incidents to DOH incompliance with NYS Operational Manual.
2. Serves as a proactive change agent promoting regulatory readiness, and assists in the integration of standards and requirements into the department.
3. Ensures the delivery of patient centered, cost-effective, quality services across the continuum of care, optimal utilization of resources and ongoing compliance with applicable local, state, federal rules, regulations and security standards.
4. Oversees and provides guidance and consultation on maintenance of policy and procedure system. Ensures policies and procedures are current with national standards of practice and in compliance with internal and external regulations
5. Provide staff education and training on regulatory/accreditation requirements to ensure continuous readiness for ongoing surveys
6. Works collaboratively with clinical and non-clinical disciplines/departments to design and implement risk management and loss prevention strategies and programs as well as performance and safety improvement programs; serves as a resource for patient/resident safety issues.
7. Manages the identification/measurement and assessment of risk through data collection, aggregation, quantitative and qualitative analysis and reporting of trends and unusual occurrences; investigates, identifies, and analyzes near misses, adverse occurrences and sentinel events and other patient/resident safety issues within the facility.
8. Management of the risk management/liability processes including reports presented to Facility committees (Executive Quality Assurance Committee), corporate committees (Quality Assurance Committee of the Board of Directors) and regulatory agencies (The Joint Commission, New York State Department of Health, NYPORTS)
9. Review legal claims and risk management data, identify systems issues and take appropriate actions to help resolve and prevent reoccurrence of identified issues
10. Provides updates on appropriate legislation
11. Provides consultative services to physicians, nurses and allied health services on risk management issues
12. Assists in evaluating and improving the value of the risk management program by assessing program completeness/effectiveness, analyzing and reporting data that demonstrates increasing value to Leadership, justifying the need for additional resources and making recommendation for program enhancement/improvement
13. Maintains formal communication processes to disseminate information relative to best practice
14. Develops and maintains effective relationships and communication with all levels of clinical and non-clinical staff in order to facilitate problem identification and resolution
15. Promotes an organizational culture of safety and ensures appropriate patient safety standards and guidelines are implemented consistently in the delivery of health care to our patient and residents
16. Functions as a liaison between the Facility and Risk Management at Central Office/Corporate
17. Maintains the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance and adhering to applicable federal, state, and local laws and regulations, accreditation requirements, and Facility policies and procedures
18. Supports and encourages error reporting throughout the Facility through a “just culture” error reporting system
19. Assumes responsibility for evaluation adherence to incident policy and procedures.
20. Assumes responsibility of day-to-day monitoring of operations of nursing to assess for risk areas.
21. Assesses nursing services by making rounds, conducting chart review and evaluating patient care.
22. Participates in a system of continuing evaluation for compliance.
23. Secures incident reports and investigations.
24. Updates and maintains required manuals. Participates in research projects as applicable.
25. Participates in operating and procedural committees as assigned.
26. Completion and Investigation of all Accidents/ Incidents (A/I) s in timely manner to ensure they comply with State Operational Manual.
27. Report all state reportable events in timely manner under NY state reportable guidelines
28. Investigate every A/I to rule out for risk of abuse and neglect and include all appropriate documents that support the investigation
29. Investigate every A/I to ensure plan of care is not been violated
30. Investigate every A/I for post incident risk assessment related to the nature of incident such as Fall Risk assessment post fall, Elopement assessment post elopement, Braden Scale to include post identification of pressure injury
31. Investigate every A/I for post incident pain and skin assessment
32. Investigate every A/I for post incident notification of family and physician
33. Responsible to notify leadership and Schedule a clinical focus meeting with leadership and IDCP (As per nature of the incident) in following events:
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Any Violation of care plan
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Any adverse event incidents
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Any incident that has the potential for neglecting a resident
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Significant Medication errors
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Allergy Errors that put a resident for potential for harm
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Sudden death
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Diet errors that put a resident at risk
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Burn
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CPR related incidents
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Restrain related incidents
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Smoking related incidents
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Any incident that can impact a group of residents
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Any incident related to claim
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Any resident or family complaint, or report or fall under reportable events, that can put patient or facility at risk
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Responsible to submit all A/I s to facility leadership team for review in timely manner.